Personal/Contact Information

Chart #.

FOR OFFICE USE ONLY

Patient Name: * * D ~--------------------~ ~--------------------~

Last

First

MI

Preferred Name

Title: IGender: *0 Male 0 Female

Mr/Ms/Mrs/etc

Family Status: * 0 Married 0 Single 0 Child 0 Other

Birth Date: *

Email Address:

SS#.

Prevo Visit:

Best time to call:

Phone: *

Home

Address: *

*

City

Drivers License or ID Number

Work

Ext

Mobile

Fax

Other Zip Code

*

Occupation:( you may select more than one)

Student D Retired 0 Homemaker

If employed, please list your occupation and name of employer:

Preferred appointment times:

Employed

o Disabled

*

Morning

Thursday

Afternoon

AnyTime

Monday

Tuesday

Wednesday

1

•

How would you like to be contacted?(please select all that apply)

Mail D Phone Email Text

Whom may we thank for referring you to our practice?

*

Another Patient, Friend, or Relative

Referral Card/Coupon

Print Advertising

D Internet Search

Yellow Pages

Medical/Dental

Office

Insurance Website

Other

*

Name of person,office,search engine, insurance site, or other referring you to our practice:

In case of an emergency, who would you like us to contact?

Please provide name,relationship, and contact information:

2

Responsible Party Information

Guarantor Information: If you are not the Guarantor(party responsible for payment or whose insurance benefits you

file under) please complete Guarantor info below:

Chart #.

FOR OFFICE USE ONLY

Patient Name:

Last

First

MI

Preferred Name

Title: IGender: 0 Male 0 Female

Mr/Ms/Mrs/etc

Family Status: 0 Married 0 Single 0 Child 0 Other

Birth Date:

Email Address:

SS#.

Prevo Visit:

Best time to call:

Phone:

Home

Address: Relation to Guarantor:

D Spouse or Dependent

City

Work

DOther

Ext

Mobile

Fax

Other Zip Code

If other was selected, please explain:

If you have dental benefits through an insurance carrier, please have your 10 card provided by

your carrier ready to scan into your file upon completion of these forms.

Response Date:

3

Dental History

Patient Name:

Last

Reason For Dental Visit:

Name of Previous Dentist and Contact info:

First

D

MI

Preferred Name

How would you rate your smile from 1 to 10? (1 being not the greatest to 10 being perfect smile):

Are you having any of the following dental/oral health symptoms?( If yes,check those that apply; if no leave blank):

Tooth sensitivities to cold temperature,sweets,bite pressure

[J Bleeding,puffy, or receding gums

Loose teeth

Difficulty or pain on chewing

DBad breath

Sores or ulcers of the cheeks, gums, tongue, or floor of mouth

Dry Mouth

Jaw joint,jaw muscle pain

Dizziness,headache, ringing in ears

Please describe if necessary:

1

Dental History, Continued

Have you ever been referred to or had exams or treatments by any of the following dental specialists:

Oral Surgeon,Orthodontist,Oral Pathologist,Endodontist,Periodontist, or TMJ Specialist

*QVes QNo

If yes, please give reason, date seen, type of Specialist, and name:

Are there any special comfort considerations or precautions that you would like us to be aware of when treating your oral

health?

*QVes Q No

If yes, please advise us below:

How are you cleaning your mouth on a daily basis?(Personal Oral Hygiene Care-POH) Please select all of the techniques

that apply:

* D Brush D Floss 0 Rinse Tongue Scraper

Other

If you selected Other, please explain and let us know the types of cleaning aids you are using(ex. electric

brush,superfloss,etc):

2

Dental History, Continued

What is the frequency of your POH care? (Please select all that apply and explain how often you use each technique): *

Daily

D After Meals

Please Explain:

D More than 1 x Daily

PM

What makes your dental appointment a great experience?

Have you ever had any complications following dental treatment? *OYes

ONo

If yes, please explain:

3

Periodontal Disease Risk and Susceptibility Assessment Questionnaire

Do you or anyone in your biological family have a history of periodontal (gum) disease? (Ex. Do your parents or siblings

have a history or early tooth loss due to gum disease)

*OVes ONo

Is there a history of diabetes in your biological family?

*OVes 0 No

WOMEN: Are you pregnant or are you nursing? OVes

ONo

Have you ever or do you currently use tobacco products?

*OVes

ONo

Do you clean between your teeth on a regular basis?

*OVes ONo

Do any drugs/medications that you are currently taking cause dry mouth or swelling of the gums?

*OVes 0 No

Has your immune system been compromised due to immuno-suppressant medication or health condition? *OVes

ONo

OFFICE USE ONL V: Score

Response Date:

4

contact@go-smiles.net

Medical/Health History

Please check any of the following that apply.(A check means yes I have or have had;and

leaving box blank means I do not have or have never had.)

Allergies to:

medications

hayfever/molds

If yes, please explain:

foods or supplements

other

o contact w/ substances

Cardivascular,Heart,Blood Disease:

Dangina

fainting or dizziness(on standing or activity)

low blood pressure

stroke high blood pressure

endocarditis or heart valve repair or replacement

Respiratory Disease or Breathing

Disorder

asthma,emphysema, or lung disease

shortness of breath

sinus problems

snoring,OSA(obstructive sleep apnea)

Skeletal(bone), Muscle,Joint pain/disorder:

D osteo arthritis

U head and neck injury

osteoporosis(bone density disorder

rheumatoid arthritis joint replacement surgery

If you selected yes to joint replacement surgery please provide date:

1

Digestive disease or GI tract or Stomach disorders:

acid reflux or GERD

D liver disorder

Urinary or Bladder Disorder

kidney disease

Endocrine Disorder

ulcers

frequent need to go

D colitis/Chrohn's disease

thyroid disease

Contagious Disease:

H IV

positive

herpes

D parathyroid disease

hepatitis

Diabetes Type 1

tuberculosis

D Diabetes Type 2

venereal disease

If you selected yes to Hepatitis, please note below type A,B,C,nonA-nonB.

If you selected yes to Herpes, please note below type oral(cold sores) or genital

Nervous System or Brain or Mental Disorders Dtremors

epilepsy/seizures/

dimentia/ Alzheimers

Parkinson's

depression/anxiety

Harmful Habits

o drug/alcohol

abuse

Dsmoker

D clenching/grinding

Current Special

Conditions/Treatments

glaucoma

cancer ,growth ,tumors

D chemotherapy

D organ transplant

o premedication advised before dental treatment

D radiation therapy

migraines/headache

2

Have you been admitted to a hospital or needed emergency care during the past two years?

*QVes

QNo

If yes please explain:

Are you currently receiving care or taking medications for any medical condition or nutritional condition? *OVes

ONo

If yes,list condition and explain:

3

Medications,Dietary Supplements, or Drugs Currently Taking:

(if you would like to provide us with a copy of your list instead, please enter "see med list" in response box)

Other conditions or explanations not previously mentioned:

4

Name of

Provider/Physician(s) other than OBGYN:

Phone Number and Contact Information:

FOR WOMEN:

birth control pills

Dpregnant

If you selected yes to pregnancy, please provide below Due Date:

OBGYN Name and Contact info:

5

contact@go-smiles.net

To the best of my knowledge, all of the aforementioned answers and information provided are true and correct. If there

are any future changes in my medical status, I will inform Dr. Friedman immediatley before my next dental appointment.

Signature:

Date:

STOP BANG Questionnaire for Sleep Apnea

Please answer the following questions:

Snoring

Do you snore loudly (louder than talking or loud enough to be heard through closed doors?)

OVes ONo

Tired

Do you often feel tired, fatigued or sleepy during daytime?

OVes ONo

Observed

Has anyone ever observed you stop breathing during your sleep?

OVes ONo

Blood Pressure

Do you have or have you ever been treated for high blood pressure?

OVes 0 No

PLEASE STOP HERE

OFFICE USE ONLY:

BMI of more than 25?

OVes

ONo

Age over 50 yrs old?

OVes

6

Neck circumference greater than 40cm? QVes

QNo

Gender male?

QVes

QNO

HeightlWeight,Age,Sex,BMI,Neck circumference

High risk of OSA: answering yes to three or more items

Low risk of OSA:answering yes to less than three items

Adapted from:

STOP Questionnaire

A Tool to Screen Patients for Obstructive Sleep

Response Date:

7

Permission to Treat a Minor(Under age 18)/or Dependent

All Patients under the age of 18 must have written permission from a parent or legal guardian to be treated by this office.

For all patients who are dependents, the Parent/Guardian or Guarantor must be present for presentation of conditions

and treatment recommendations, or if not present, be available by phone for this presentation and consent in writing for

treatment. If a time of emergency or health crisis occurs when some unforseen health incident happens, at that time, it

would always be better to have the Guarantor,Parent/Legal Guardian available for emergency/treatment care permission.

In the case of a threat to the minor's/dependent's health and well being, in the absence of the Parent or Guardian,

permission of emergency treatment /care is hereby given.The Doctor should proceed in the best interest of the

minor/dependent by instituting appropriate measures such as CPR, calling paramedics,etc. in compliance with Maryland

Minor Consent Laws.

Patient Name:

Last

First

MI

Preferred Name

I hereby give permission by my electronic signature below for the above patient to receive dental care from the

practitioners in this Dental Office, Stephen J. Friedman D.D.S. and his duly licensed or certified associates.

Signature:

Date:

contact@go-smiles.net 0 0 0

~:-~ ' .. "~ :..... '. ". :

'------- __ ---' D

6

Health Promotion Partnership

We invite you to be a partner with us in creating a health care team that will:

1) help you achieve your oral health goals; and

2) maintain that high level of health throughout your life.

Together we can achieve this by monitoring the health status of your teeth,

gums, and oral structures, and examining how your habits and life-style can

influence your overall health. We can then create your personal plan to help you

reach your health goals, and provide feedback at regular periodic visits that will

help you reach and stay at this high level.

In order to achieve these goals communication is of great importance. We will

use the lines of communication that work best for you for the purpose of

appointment confirmations, reminders, and periodic health information updates

and bulletins. This entails utilizing the most current contact resources such as

e-mail, texting, cell phone, facebook, and fax.

With your acknowledgment and participation, our team will support you with

timely appointment and preventive visit reminders and follow-up if you should

miss a visit and provide various health screenings and preventive coaching to

keep you healthy and on purpose for achieving your general and oral health

goals.

This collaboration will help you stay at a high level of oral health for your

lifetime and this in turn will provide peace of mind, confidence in your smile,

comfort, and overall health.

1

contact@go-smiles.net . , ,

contact@go-smiles.net

To join us in this Partnership we invite you to fill

in the information below and

sign the acknowledgment.

I would like to partner with my dental team;

Dr. Stephen J. Friedman, DDS, PA, Dentistry to Enhance Your Smile, to establish a dental

disease prevention and health promotion partnership that will:

1) help me design a plan to get my mouth into optimal health,

2) establish the best periodic intervals for hygiene services to maintain my oral health, 3) monitor and coach me to better health choices through understanding how lifestyle effects

my health. I will do my best to receive and respond to communications from the office and to confirm

and keep my appointments, and keep my contact information up-to-date.

Name

I am available for phone calls:

* 0 Monday Tuesday

DWednesday

Thursday

o Friday

Saturday

From(AM)

To(PM)

Sunday

2

You may phone me at my place of work.

·QVes Q No

You may phone me at home evenings(After 5pm)

·QVes QNo

My Email is:

I acknowledge that I would like to participate in this health partnership and enjoy these benefits:

QVes QNo

3

Terms and Understandings

Definitions: Participating Entities

Patient Name:

Last

, hereafter referred to as The Patient.

First

MI

Preferred Name

2. The patient, his or her Parent or Guardian, or any other entity guaranteeing payment for services rendered to the

Patient, hereafter referred to as The Responsible Party.

3. Dr. Stephen J. Friedman, D.D.S., PA at 1370 Lamberton Drive, Silver Spring, MD; hereafter referred to as This Dental

Office.

4. Dr. Stephen J. Friedman, DDS, and associate dentists and employees; hereafter referred to as Practitioners of this

Dental Office.

As the Responsible Party, I the undersigned understand and agree to the following:

I am responsible for payment of the cost of services rendered to the Patient by the Practitioners of this Dental office.

Payment is due at the time of service. If I desire alternative arrangements for payment of services, arrangements with the

financial secretary must be made in writing in advance of services rendered. I will furnish This Dental Office all

reasonable information necessary to treat the Patient including health history, employment, insurance, and contact

information where applicable. (See page 5)

I may request written fee estimates in advance of any dental services rendered. This Dental office will make such

requests available and will honor these estimates for up to six months. After that time period has elapsed , fees may

change without notice. Any fees quoted that are reduced by estimated dental plan benefits from the Patients dental

insurance companies or third party carriers cannot be guaranteed by this Dental office.

4

~ __ -----,D

contact@go-smiles.net

Terms and Understandings, Cont.

At my written request, as a courtesy to the Subscriber (the owner of the dental benefit pian), this Dental Office will submit

claims and predetermination of benefits requests to the Subscriber's dental insurance company and/or third party

carriers. Because these insurance companies and third party carriers are agents of the Patient, any benefits that these

companies estimate or pay for the Patient cannot be guaranteed by this Dental Office. This Dental Office will accept

assignment of Dental Benefits from Dental Insurance Companies with whom we participate and at it's discretion will

accept assignment from other Dental Insurance Companies that make payment in a timely manner. Paymnet due on any

portion of the cost of dental services rendered to the Patient by this Dental Office and not covered by the Patient's dental

insurance company or third party carrier regardless of the insurance company's or third party carrier's estimate or stated

intention is my responsibility.

My account is overdue if payment is not received at the time of service and no financial arrangements have been made in

writing, or if payment is not received by the date agreed upon in prior financial arrangements. If my account is overdue, a

service charge, not to exceed 1.5% per month may be added to the outstanding balance due for each month or fraction

thereof that is overdue. If my account is overdue, the entire account balance will become due immediately, and such an

account may be transferred to a collection agent representing this Dental Office for further action. I am responsible for all

costs and reasonable attorney's fees for collection of any overdue accounts. I am aware that contacting this Dental Ofiice

immediately in the event of an overdue account will mitigate collection activities and costs.

Signature:

Date:

5

Stephen Friedman D.D.S

NOTICE OF PRIVACY PRACTICES

This notice describes how health information about you may be used and

disclosed and how you can get access to this information.

Please review it carefully.

The privacy of your health information is important to us.

Our Legal Duty

We are required by applicable federal and state law to maintain the privacy of your health information. We are also

required to give you this Notice about our privacy practice, our legal duties, and your rights concerning your health

information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes

effect 1/1/14, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are

permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our

Notice effective for all health information that we maintain, including health information we created or received before we

made the changes. Before we make a significant change in our privacy practices, we will change the Notice and make

the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional

copies of this Notice, please contact us using the information listed at the end of this Notice.

Uses and Disclosures of Health Information

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatments: We may use or disclose your health information to a physician or other healthcare provider providing

treatment to you.

Payment: We may use and disclose your health information in connection with our healthcare operations. Healthcare

operations include quality assessment and improvement activities, reviewing the comptence or qualifications of

healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation,

certification, licensing or credentialing activties.

Your Authorization: In addition to our use of your health information for your treatment, payment or healthcare operation,

you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you

1

contac~@go-smiles .net

give us an authorization, you will revoke it in writing at any time. Your

revocation will not affect any use or disclosure

permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or

disclose your health information for any reason except those described in this Notice.

To your family and Friends: We must disclose your health information to you, as described in the Patient Rights section

of this Notice. We may disclose your health information to a family member, friend or other person to the extent

necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including

identifying or locating) a family member, your personal representative or another person responsible for your care, of your

location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we

will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency

circumstances, we will disclose health information based on a determination using our professional judgment disclosing

only health information that is directly relevant to the person's involvement in your healthcare. We will also use our

professional judgment and our experience with common practice to make reasonable inferences of your best interest in

allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain

circumstances. We may disclose to authorized federal officials health information required for lawful intelligence,

counterintelligence, and other national security activities. We may disclose to correctional institution ot law enforcement

official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders

(such as voicemail messages, postcards, or letters).

Patient Rights

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request

that we provide copies in a format other than photocopies. We will use the format you request unless we cannot

practicably do so. ( You must make a request in writing to obtain access to your health information. You may obtain a

form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable

cost based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the

address at the end of this Notice. If you request copies, we will charge you $0.50 for each page, $2.00 per hour for staff

time to locate and copy your health information, and postage if you want copies mailed to you. If you request an

alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we

will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at

the end of this Notice for a full explanation of our fee structure.)

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed

your health information for purpose, other than treatment, payment, health care operations and certain other activities for

the last 6 years, but not before April 14,2003. If you request thsi accounting more than once in a 12-month period, we

2

may charge you a reasonable, cost-based fee for responding to these additional requests.

Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health

information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement(

except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your health information by

alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the

alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative

means or location you request.

Amendment: You have the right to request that we amend your health information. (Your request must be writing, and it

must explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled d to receive

this Notice in written form.

Questions and Complaints

If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or disagree with a decision we made about access to

your health information or in response to a request you made to amend or restrict the use or disclosure of your health

information or to have us communicate with you by alternative means or at alternative locations, you may complain to us

using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S.

Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S.

Department of Health and Human Services upon request.

We support you rirght to the privacy of your health information. We will not retaliate in any way if you choose to file a

complaint with us or with the U.S. Department of Health and Human Services.

Contact Officer: Office Manager

Telephone: (301 )681-8200

Fax:(301 )681-71 06

Address: 1370 Lamberton Drive Suite 18 Silver Spring, MD 20902

Response Date:

3

1~onta9t@go:sIT!iles.net .. ' , ,,:'" "",.... , , ~ ';. . ~~ '. ~~ ~. ,

Stephen J. Friedman D.D.S, P.A.

Acknowledgement of Receipt of Notice of Privacy Practices

***You May Refuse to Sign This Acknowledgement*** Patient Name:

Last

First

MI

Preferred Name

The above named has received/viewed a copy of this office's Notice of Privacy Practices.

*QVes Q No

Signature: Date:

Response Date:

7

~ ______________